Do Not Type a Space ...
following a period with an abbreviation
following a period used as a decimal point
between quotation marks and the quoted
material “squeaky sounds” in ears
before or after a hyphen mid-August
before or after a slash allergies/
before or after a dash 50-70%
between a number and percent sign 50%
between parentheses and the enclosed
material Irritable bowel syndrome
between any word and the punctuation
following it. Irritable bowel syndrome,
between the number and the colon used to
indicate a dilute solution or ratio. 1:2 ratio
was used in his anesthesia.
on either side of the colon when expressing the
time of day 12:00 p.m.
before an apostrophe The patient’s mother
was present during this evaluation.
before or after a comma used within numbers
before or after an ampersand in abbreviations, e.g.,
on either side of the colon when expressing ratios
after the closing parenthesis if another mark of
punctuation follows Irritable bowel syndrome
after a comma
after a semicolon
after a period following an initial
after the closing parenthesis
on each side of the x in an expression of
dimension, e.g. 4 x 4
after punctuation at the end of a sentence
after a colon except when expressing time or a
after periods on itemized or enumerated data
under plan/assessment. Example: 1. (2 tab
spaces) Return to see me in 2 weeks.
**Numbers: Spell out the numbers 1 to 9 if they are
referring to an English word, or if they are referring to an
approximation. Zero is generally spelled out. Numbers 10
and above should always be in figures.
Use Numerals for clarity and so they stand out from the
The patient was brought to the ER 1 hour after the
The patient has been seen 3 times in the last month.
Height 5 foot 5 inches, weight 130 pounds.
There are exceptions to every rule. Use your judgment and keep in
mind that clarity is always the goal. You may sometimes encounter
numbers in approximation, but followed by a unit of measure. This
is an EXCEPTION to our rule.
D: Approximately 5 mL of blood loss.
T: Approximately 5 mL of blood loss.
There were hundreds of patients in the emergency
The patient is approximately six years old
The patient is approximately 60 years old.
The patient is about two months postoperative now.
The abrasion was about 1 cm in size.
Adjacent Numbers - Spell out two consecutive
numbers to avoid confusion.
Take two 275 mg tablets daily.
Alor 5/500 one to two tablets q.4-6 h. p.r.n.
Three 2-inch bandages.
Use a comma between neighboring and unrelated numbers
when neither can be easily expressed in words and the
sentence cannot be reworded. E.G. During the month of
June 1999, 5299 prescriptions were dispensed.
Fractions - According to the dictation style, spell
out or use numerals for common fractions
D: One and one-half hours ...
T: 1-1/2 hours ...
He smokes two packs and a half of cigarettes per day.
He smokes 2½ packs of cigarettes per day.
He smokes 2-1/2 packs of cigarettes per day.
(Note the use of the hyphen in mixed fractions if the
subscript is not used.)
He has a 30-pack-year cigarette habit.
Use decimal fractions with the metric system. 1.5 cm
Use common fractions with the English system. 1-1/2
Beginning a Sentence - Do not use a numeral to
begin a sentence. Spell out the number or recast the
D: 10 mg of Reglan was administered stat.
T: Reglan 10 mg was administered stat.
Exception - It is acceptable to begin a sentence with a year,
although recasting the sentence is preferred.
Acceptable: 2000 is going to be a prosperous year.
Preferred: The year 2000 will be prosperous.
Plurals - With single-digit numbers, use ‘s
4 x 4's
To form the plural of multiple-digit numbers, do not use an
She was in her 30s
He was last hospitalized in the 1970s
Arabic Numerals (0, 1, 3, etc.) Versus Roman
Numerals - as a general rule, most numbers will be
expressed in Arabic numbers unless Roman numerals
are specified or preferred.
Grades are generally expressed in Arabic numbers.
grade 4/6 murmur
CIN grade 3 or CIN-3
Developmental dysplasia, Crowe grade II (Exception
- Not Crowe grade 2)
Stages are generally expressed in roman
numerals especially with CANCER staging,
with some exceptions
stage III decubitus ulcer
ovarian cancer, FIGO stage IV
stage 3 Garden fracture (Exception - Not
stage III Garden fracture)
Diabetes - The American Diabetes
Association adopted the use of Arabic
numbers for clarity.
Diabetes type 1
Diabetes type 2
Cranial Nerves - Roman numerals are preferred.
Cranial Nerves I-XII
Apgar Scores - Use numerals for ratings and spell
out numbers relating to minutes to draw attention
to the scores. Apgar is not an acronym.
The Apgar scores were 6 and 9 at one and five
Zero - The number zero is spelled out when
There was zero response to the medication.
The temperature outside dropped to zero.
Always use a zero in front of a fractional number
less than zero
Ordinals - Ordinal numbers are used to indicate
order or position in a series rather than a quantity.
Ordinals are commonly spelled out, especially
when the series goes higher than 10 items.
However, as with all numbers in medical reports,
AAMT recommends using numerals: 1st, 2nd, 3rd,
Do not use a period with ordinal numbers.
3rd rib (or third)
5th finger (or fifth)
She is to return for her 3rd (or third) visit in 2
She was in her 9th or (ninth) month of
His return visits are scheduled for the 15th
and 25th of next month.
Commas - Use commas only if there are 5 or more
digits when expressing numbers
Time- Use numbers separated by a colon, except for
even periods of time. Do not use colons with military
time. Do not use numbers for midnight and noon.
The office closes at 8 a.m.
Her appointment was at 10 a.m.
MILITARY HOURS: 2300 hours, 1500 hours, 0830
Noon, not 12 p.m. or o’clock; midnight, not 12 a.m. or
Transcribe dates in full.
D: Blood was drawn on 10-11-05.
T: Blood was drawn on October 11, 2005.
D: Admitted on February twenty second
T: Admitted on February 22 NOT 22nd
D: Admitted on the second of February
T: Admitted on the 2nd of February.
D: Admitted on February the second
T: Admitted on February the 2nd.
D: Admitted on the second of February of this year
T: Admitted on February 2, 2006
*Complete date format.
D: Admitted on February of this year.
T: Admitted on February 2006.
*Delete the word of. This is assuming that the date of report is current.
D: On February of two thousand and six, she was admitted for…
T: On February 2006, she was admitted for…
D: second grade
T: 2nd grade
D: fourth year in high school
T: 4th year in high school
D: two to fours days
T: 2 to 4 days (not hyphenated)
D: approximately two to four days
T: approximately two to four days (approximation)
D: ten to fifteen percent
T: 10-15% (hyphen due to the symbol) or 10% to 15%
D: ten to fifteen hertz
T: 10 to 15 Hz
D: L4 to S1
T: L4 through S1
D: L4 dash 5
Use tsp for teaspoon
Use tbsp for tablespoon
Spell out Fahrenheit IF degree is spelled out -
98.6 degrees Fahrenheit.
Spell out Celsius IF degree is spelled out. 36
If dictated, spell out degrees. 98.6 degrees
If degrees not dictated, do not transcribe
unusual units of
Dictated as Transcribed as
0.8 centimeters squared 0.8 sq cm
22 millimeters of mercury 22 mmHg
3.0 liters per minute 3.0 L/min
40 millimeters per hour 40 mm/h
8 grams percent 8 gm%
Spell out a symbol when used alone (with no
Use symbols when they are used with numbers
Dictated as Transcribed as
Four to five 4 to 5
Number 3 0 #3-0
Twenty-twenty vision 20/20
BP 120 over 80 120/80
Grade two over six 2/6
Three point five centimeters 3.5 cm
Point five centimeters 0.5 cm
Abbreviations when the words they represent are capitalized
Autism Spectrum Disorder/Pervasive Developmental
The first word following a colon if it begins a complete sentence
or is part of an outline entry HEENT: Normocephalic
Most abbreviations of English words I.V.
The names of the days of the week, months, holidays, historic
events and religious festivals Wednesday, February,
The names of specific departments except when it follows the
word consult, ward/suite Neurology but radiology
consult, pediatric ward
The trade or brand names of drugs
A quote when it is a complete sentence
The seasons of the year winter, spring,
The common names of diseases
Generic drug names
The common noun following the brand name.
Example - Tylenol tablets
Designations based on skin color, like "a tall
Use hyphens when numbers are used with
words as compound modifiers preceding
3.0-mm Johnson & Johnson stent
a #7-French sheath or a 7-French sheath
when the word “number” is not dictated
3 x 2-cm mass
13-year 2-month-old girl
The patient is 34-year-old woman, but
the woman is 34 years old.
Use hyphens to join some compound nouns
with numbers as prefixes. Check appropriate
references for specific terms.
Use hyphens in compound numbers from 21 to
99 when they are written out. Note: The only
time they should be written out is at the
beginning of a sentence.
three hundred eighty-nine
A hyphen versus to/through
The values are accompanied by a symbol.
He is to take 1 to 2 tablets of Tylenol every 4
to 6 hours p.r.n.
Blood pressure was in the 140 to 160 range
Office hours are 1 through 4 p.m.
There is a 40-50% occlusion
Ante Intra semi
Anti Micro sub
Bi mid super
Co Non supra
Contra Over trans
Counter Pre tri
De post ultra
Extra Pro un
Infra Pseudo under
Inter re weight
Do use a hyphen with prefixes ending in a or i and
a base word beginning with the same letter.
Example - anti-inflammatory.
Do use a hyphen when compounded with the
Example - self-administered drugs, self-
For Clarification - Use a hyphen after a prefix if
not using a hyphen would change the meaning of
the word. Examples - re-cover (to cover again)
versus recover (regain)
Stage and grade - do not capitalize either one if
it does not begin a sentence.
Use Roman numerals for cancer stages.
Use Arabic numerals for cancer grades.
For clarity, use capital letters or arabic suffixes
without spaces or hyphens.
stage I stage IA
stage III stage IIIA stage IIIB
If dictated q.day - transcribe q.d.
If dictated q. four hours - transcribed as q.4 h. or
every 4 hours not q. 4 hours
When referring to drugs including strength, dosage
and directions - Use Arabic numerals only. Example -
The patient was prescribed penicillin 500 mg
t.i.d. for 5 days.
If there is no whole number, always add a 0 in front of
the decimal point for clarity - this is a general rule
when transcribing numbers, not just medications.
Example - Dictated as Synthroid point 75 mg a day.
Transcribe as Synthroid 0.75 mg q.d.
Of note also (as seen in the example above),
transcribe a day as q.d. when referring directly to
the medication frequency. Twice a day for b.i.d.,
three times a day t.i.d. and four times a day, q.i.d.
Be aware that some drugs are commonly dictated in either
milligrams or micrograms. Example - Synthroid 0.05 mg or
Synthroid 50 mcg.
Unless it begins a sentence, use lowercase - vitamin.
Capitalize the letter, if available use subscript for the number.
Do not leave a space between letter and number: B12 or
Use commas to separate multiple related test results. Here
are some examples:
Creatinine 1.2, BUN 42, phosphorus 4.3.
WBC 12.4 with 72 segs, 9 lymphs.
CBC reveals an RBC count of 10.2, WBC 6.8, platelets 220,000,
reticulocyte count 1 with 3 monos, 1 eos and 0 basos.
Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100
and glucose of 80.
Use periods or semicolons (as necessary) to separate
unrelated laboratory test results. For example,
Potassium 3.7. TSH 1.0. Albumin 4.0.
Laboratory tests include potassium 3.7; TSH 1.0; and albumin
Names with junior or senior attached. Use a comma
before and a period after the abbreviation or use
Example - Jeramiah Johnson, Jr. or Jeramiah
Incorrect - Jeramiah Johnson Jr.
Names with ordinals. Do not use comma between
name and ordinal.
Example - Bernie Schwartz III
Incorrect - Bernie Schwartz, III
BUT IF FORMATTED AS LAST NAME, FIRST NAME:
Johnson, Jeramiah, Jr. and Schwartz, Bernie,
You will encounter dictators saying “He” or “She” at the
start of the report. You should edit this to become “The
patient”. This is to identify the patient. After you have
identified the patient, then it is alright to transcribe he, or
she in the succeeding sentences. Example:
D: He is here today for a follow up for his graft. He was last
T: The patient is here to today for a follow up for his graft.
He was last seen on…
Edit the obvious grammatical errors and inconsistencies in
patient’s sex. If you cannot determine the actual sex of the
patient, then edit the pronouns to become “the patient.”
Do not start a sentence with the word “also,” even if
dictated. You should recast the sentence.
Be very careful with your punctuations.
You do not need to supply articles and prepositions if not
dictated, and if the sentence can stand on its own.
Itemize the diagnoses/assessment and plan if more than one
Itemize discharge medications in a Discharge Summary.
Put a comma before the words “but” and “which” if there are
more than four words after them.
Edit redundancies, but be very careful not to alter the style of
Always transcribe the words laboratory and examination in
full even if dictated as labs and exam
History of Present Illness - Mainly in present
tense, but mixed tense may be appropriate.
Or REASON FOR VISIT or CHIEF COMPLAINT
The main reason for consultation
SUBJECTIVE: If all data under this heading
contains, the patient states/denies/says/notes IF
NOT USE HISTORY:
Past Medical History - Use past tense.
BUT: The patient has hypertension NOT the
patient had hypertension. (since hypertension
is a condition that is currently present)
Allergies are typed either ALL CAPITAL LETTERS
if not drugs or medication or bold font for
Example - If the allergy is dictated latex, type
LATEX. If dictated as allergy is Cymbalta, type
Transcribe in continuous paragraph format, except when
the doctor numbers the medications. Example: Penicillin
500 mg t.i.d. for 5 days, levothyroxine 0.75 mg q.d. and
Lopressor 50 mg b.i.d.
Capitalize brand name medications. DO NOT capitalize
Use Latin drug abbreviations when dictated. Example - if
dictated every day - transcribe q.d. If dictated every four
hours - transcribe every 4 hours.
Don't mix Latin and English terminology. Example: If
dictated q. day - transcribe q.d. NOT q. day.
When referring to strength, dosage and directions - Use
Arabic numerals only.
If there is no whole number, add a zero in front of the
decimal point for clarity. This is a general rule when
transcribing numbers, not just medications. Example:
Dictated as Synthroid point 75 milligrams a day. Transcribe
Synthroid 0.75 mg q.d.
Transcribe in present tense whenever applicable or
Subheadings under review of systems
should contain only the systems while
under physical examination subheadings
should be specific anatomical part even if
dictated as system.
REVIEW OF SYSTEM:
GENITOURINARY (even if dictated as urinary tract)
SKIN (even if dictated as dermatologic)
No abbreviated medical terminology. Type the entire
term or phrase. Example - If the doctor dictates CAD,
type coronary artery disease. PNA transcribe
as either PERMANENT or PARTIAL NAIL
AVULSION (ANALYZE THE SENTENCE)
Numbers follow the same rules for any section of the
transcript. Example - A 31-YEAR-OLD FEMALE. 5 MG.
Anatomical parts are not spelled out. MTPJ, DIPJ
Use past tense:
In the past history of a report
In discharge summaries EXCEPT for the History of
Present Illness and the Physical Examination sections.
When discussing expired patients
Use present tense:
To describe mostly information under physical
Use the correct verb tense to communicate the
appropriate time of the action. Even if the dictator
inadvertently changes tense during the dictation.
Fill in blanks or make notes
Consistent pronouns - he or she?
Consistent tense - was or is?
Singulars versus plurals - sclera or sclerae?
Headings - Are they labeled properly?
Sound-alike: heel vs. heals; maybe vs.
Unnecessary awkward repetitions or redundancies
No abbreviations in diagnoses except anatomical
parts when dictated as such.
Drugs correctly capitalized
Formatting, headings and indentations
Proper use of hyphens